Not all transgender people want surgery, nor should surgery be held up as the gold standard for someone to completely transition to their gender identity. But for those who do want to go through with procedures to alter their genitalia, they must first jump through hoops that some doctors and advocates have argued recently are unethical.

The World Professional Association for Transgender Health (WPATH) has now published seven iterations of its guidelines for doctors who treat transgender people. The guide outlines the steps health professionals should take to ensure that a patient is treated well, and cared for appropriately. The report covers all kinds of things, from hormone treatments to voice and communication therapy, but a recent study singled out one particular recommendation: Right now, WPATH suggests that any individual seeking genital reconstructive surgery should be asked for two mental-health referrals before going through with the procedure.

The referrals are both required to list things like the patient's diagnosis, their identifying characteristics, their consent, and a rationale for the surgery. For context, trans patients who want elective chest surgery, such as mastectomies or breast augmentation, are required to get just one mental-health referral.

For further context, the new study notes that outside transgender healthcare there are very few procedures that require two health referrals, and they’re extreme cases, things like partial lobotomies for those with severe OCD or depression and electroconvulsive treatment for acute psychiatric illness. And non-trans patients who want access to genital surgery aren’t asked for any mental-health referrals for procedures. A non-trans man who suffers from chronic pain of the scrotum, for example, can elect to have an orchidectomy—a procedure to remove both testicles—without a mental-health referral. Nor would a non-trans woman seeking a hysterectomy be asked to see two mental-health professionals. Likewise, there is no mental-health requirement for cosmetic surgeries like breast augmentation or rhinoplasty for non-transgender people, according to the American Society for Aesthetic Plastic Surgery.

In light of all this, the recent paper, published in Sexual and Relationship Therapy, calls into question the two-signature suggestion. The paper, titled “Yes and yes again: are standards of care which require two referrals for genital reconstructive surgery ethical?” goes through the reasons why doctors might have asked for two referrals, and ultimately concludes that two signatures are both unnecessary and unethical. “Applying the two written qualified mental-health professionals opinion rule to all trans people, rather than those for whom it is clinically indicated, appears to be disproportionately prejudicial where the impact is delay, obstruction, and differential treatment,” they write.

WPATH should change their recommendations,” lead author Walter Pierre Bouman, a psychiatrist and the director of the Nottingham National Centre for Gender Dysphoria told me in an email, “which are based on consensus rather than on evidence-based medicine.”

There are a lot of reasons why asking for two signatures might be reasonable. These surgeries are irreversible and involve removing healthy tissue, so performing them on someone who might be suffering from psychiatric complications, or who might come to regret it, would certainly be bad. And not all doctors are actually qualified to perform genital reconstruction, and might take advantage of people—putting barriers between patients and bad doctors can be a good thing. (At least one such case does exist. Dr. Russel Reid, a physician working in the U.K., pushed several patients towards surgery and was later found guilty of medical misconduct in a case that was controversial in the transgender community.)

On the flip side, recent research has shown that trans people are no more likely to suffer from mental illness than cisgender people are. And the rate of regret among trans patients who undergo surgery is extremely low—something like two or three percent. In fact, most studies suggest that gender-confirming surgeries vastly improve the quality of life of individuals who choose to go through with them. And the fact that the same surgery applied to a different person—as in the case of the above orchidectomy example—changes the requirements, suggests that something unequal is going on. “From an ethical standpoint we really need to think about this in a way that’s ethical across all populations, and that’s not how things are right now,” said Kristen Eckstrand, the co-director of the Program for LGBTI Health at Vanderbuilt University.  

Eckstrand also points out that asking for more medical intervention is particularly difficult for transgender people, who are far more likely to face discrimination and stigma in the doctor’s office. Studies show that transgender people are less likely to seek out healthcare, and when they do, often face doctors who don’t know what they need. “We know that a good portion of transgender people who do access medical care end up teaching their provider about their needs and bodies,” she said. “The medical environment is tough for anyone but it’s particularly tough for transgender people.”

This isn’t to say that there should never be any mental health-checks on those seeking gender confirmation surgeries. “Note we are not arguing for an 'anything goes' approach,” Bouman wrote in the paper, “rather that, when undertaken within a multidisciplinary/interdisciplinary team, it is possible to provide a robust assessment and ongoing support to stable trans people such that the two-signature approval system is not necessary.”

Eckstrand says that to properly help transgender people, doctors should stop thinking about checklists and start paying attention to the needs of their individual patients. “As providers we need to do due diligence in figuring out what the best way to provide care for these individuals, and that can’t be a mental health check box.”

Alice Dreger, a historian who studies gender and medicine at Northwestern University’s Feinberg School of Medicine, agrees. “For some people, it’s crazy to require two signatures by mental-health professionals," she told me in an email. "They are genuinely fully informed already, have done a lot of thoughtful processing on their own, and know what they need. For some, screening by two people may not be enough. So it’s an imperfect model of care, to be sure, especially when you have mental-health professionals who vary all the way from genuinely anti-trans to anti-screening.”

That spectrum of care Dreger mentioned doesn’t just exist when it comes to the experience and points of view of mental-health professionals. It also exists geographically. Because the healthcare systems in Europe and the United States are so fundamentally different, these regulations impact transgender people living across the ocean quite differently. The WPATH standard of care guidelines aren’t technically rules—the organization simply writes their recommendations for the standards they think are appropriate. But in Europe the double referral is standard, Bouman says. “It is a requirement in the U.K., as it is in most other European countries,” he said.

In the United States, on the other hand, the two-referral suggestion is often not an issue. This isn’t because the U.S. is exceptionally fair to trans people, but rather because health insurance won’t pay for genital reconstructive surgeries in the first place, says Shannon Minter, legal director of the National Center for Lesbian Rights. (Minter himself transitioned 18 years ago at the age of 35.) Until recently, every state had a ban on any kind of Medicaid reimbursement for gender confirming surgeries. Most private insurance plans don’t cover them either. So trans people who want to pursue surgery are forced to finance their own procedures. “When you pay out of pocket, this two evaluation issues doesn’t tend to  come up,” Minter said. In other words, those who are having to pay out of pocket for their own surgeries often simply pay the surgeon directly, rather than going through the standard channels.

Recently, things have been changing in the U.S.—nine states now prohibit private health insurance companies from discriminating against transgender people. In February of this year California expanded its Medicaid program to include sex confirming surgery. In March transgender activists succeeded in getting rid of Medicare rule that prohibited coverage of gender confirming surgeries. More and more private companies are providing coverage.

This is all good news for trans people in the U.S., but it also means that they’re likely to start facing the two-referral barrier. As more insurance plans start covering gender confirming surgeries more will likely turn to WPATH for guidance. That means that many of these new policies will likely incorporate the two signature mandate, says Minter. “It’s great that they’re covering these surgeries,” he said, “but a lot of these policies are requiring those two signatures.” This Aetna policy, for example, requires two referrals, as does this one from Blue Cross Blue Shield.

Bouman told me that since sending the paper to a few WPATH members the organization has formed a working group to revisit their recommendations. “I expect WPATH to publish a revision regarding this issue in 2015,” he said.